Appendicitis is one of the most frequent surgical emergencies in adult and pediatric populations [
We searched the medical literature during August 2017 to identify cases of empyema in the setting of appendicitis. Reports presenting patients with thoracic empyema or lung abscess as a complication of appendicitis in the preoperative or postoperative period were eligible. Two independent investigators (GVR and LCA) reviewed abstracts through PubMed, MEDLINE, LILACS, and SciELO in either English or Spanish language. Any discrepancy was solved by consensus among the authors. Search terms included (Mesh) [appendicular mass AND empyema]; [appendicitis AND empyema]; [appendicular abscess AND empyema]; [appendicitis AND respiratory distress]; [appendicitis AND pleural infection] and [appendicitis AND lung abscess]. Those articles meeting the eligibility criteria were reviewed in detail. Additionally, we complemented the literature search by reviewing Google/Google Scholar and previous references. The information was collected in case forms and analyzed with Microsoft Excel 2016. Figure
Flowchart of the literature search and articles included in this study.
An 11-year-old boy presented to the pediatric emergency department with right lower quadrant abdominal pain, vomiting, and fever for the past 4 days. In addition, he endorsed decreased appetite and no bowel movements. His mother mentioned that the patient took ibuprofen 48 hours prior to presenting to our institution. Upon examination, vitals were as follows: BP: 90/60 mmHg, HR: 128 bpm, RR: 28 rpm,
Blood tests showed a WBC count of 29.7 × 103 cells/mm3 (
By day 3, the patient remained febrile. He developed severe respiratory distress, abdominal distention, and rebound tenderness. A computed tomography (CT) scan of the abdomen and pelvis revealed a secondary peritonitis for which an emergent open laparotomy was conducted. During the procedure, he was noted to have an appendicular abscess with 150 cc of pus and small collections throughout the pelvis. A few hours after surgery, the patient presented respiratory distress and hemodynamic decompensation. A chest X-ray revealed a large right-sided pleural effusion (Figure
(a) Large right-sided pleural effusion and (b) evacuation of empyema after chest tube placement on the right side of the thorax.
Axial view of the thoracic empyema. No underlying parenchymal disease was noted.
We identified 10 cases of patients presenting with appendicitis and empyema (Table
Cases of appendicitis associated with empyema.
Sex | Age | Risk factor | Isolated organism | Country | Outcome | Author |
---|---|---|---|---|---|---|
Male | 5 | Child |
|
USA | Survived | Stein et al. [ |
Female | 50 | — |
|
USA | Survived | Law et al. [ |
Male | 5 | Child |
|
USA | Survived | Law et al. [ |
Male | 5 | Child |
|
USA | Survived | Herline et al. [ |
Female | 3 | Child |
|
Taiwan | Survived | Kao et al. [ |
Male | 8 | Child | None | New Zealand | Survived | Wong et al. [ |
Male | 68 | Elderly |
|
Spain | Survived | García et al. [ |
Female | 31 | Pregnant | Gram-positive coccus | Argentina | Survived | Dietrich et al. [ |
Female | 24 | — |
|
Turquía | Survived | Tokat et al. [ |
Female | 2 | Child | None | USA | Survived | Betancourt et al. [ |
In this report, we present a young patient who was admitted for conservative management of an appendicular mass. His clinical course was complicated with severe respiratory distress due to a thoracic empyema that was diagnosed postoperatively. This complication may appear despite a relatively early identification of the appendicular mass and prompt initiation of antibiotic therapy. A review of this topic including the pathophysiology of thoracic empyema, clinical scenarios, and potential outcomes is discussed.
Thoracic empyema may present in either young or elder individuals (2–68 years). However, pediatric patients are most frequently affected (60%), probably reflecting a difference in the pathological aspects of this condition between both groups. While in adults the omentum can contain the inflammation affecting the appendix, in children the omentum is underdeveloped and unable to limit purulent leakage [
Bacterial passage from the abdomen to the thorax is possible due to several mechanisms. For example, the pressure gradient between both compartments may cause a valve effect that favors the mobilization of intra-abdominal content to the thorax. Additionally, unilateral lymphatic flow is another factor described to play a role in the dissemination of pus across the diaphragm [
Although our patient presented with obvious symptoms and signs of appendiceal phlegmon, it is possible that the previous use of oral nonsteroidal anti-inflammatory drugs prevented an early presentation to our ED. This situation posed the patient at an increased risk for complications such as abscess formation and peritonitis [
Table
More invasive therapies such as early appendectomy are technically challenging, especially at the time of manipulating inflamed tissues or closing the appendiceal stump [
Survival rate of patients with an appendiceal mass or abscess who develop thoracic empyema is 100%. This could be related to the aggressive surgical management and abscess washout once the patient begins to deteriorate [
To the best of our knowledge, this is one of the few cases that present an appendiceal mass complicated with thoracic empyema. It can arise despite early identification and management of an appendiceal mass or abscess. Physicians should be aware of this complication during the perioperative state of appendicitis. Finally, the abdomen should be carefully evaluated when patients develop thoracic empyema without a clear parenchymal lung disease.
Written consent was obtained from the patient’s mother, and verbal consent was obtained from the patient for data publication and any accompanying imaging.
The authors declare that there are no conflicts of interest related to the publication of this case report.
George Vasquez-Rios and Lesly Calixto-Aguilar drafted the manuscript. George Vasquez-Rios and Lesly Calixto-Aguilar conducted the literature search. George Vasquez-Rios, Lesly Calixto-Aguilar, Richard Pajuelo, and Wilder Alarcon were part of the medical team responsible for the patient care. George Vasquez-Rios, Lesly Calixto-Aguilar, Richard Pajuelo, and Wilder Alarcon critically revised and edited the manuscript. All the authors significantly collaborated with the intellectual aspects of the manuscript. All the authors reviewed the final manuscript and approved the final version of it.